By Samer Al Hadidi, MD, MS, FACP
In the U.S., trainees spend at least 6 years in training after completing medical school prior to practicing as oncologists. This includes training in either internal medicine (3 years) or pediatrics (3 years), or combined internal medicine-pediatrics (4 years). Hematology-oncology training usually extends for another 3 years. Most trainees enter a job immediately after training, though many others pursue an advanced fellowship after hematology-oncology training prior to starting their actual jobs. Advanced fellowships resemble a common pathway for many trainees who want to secure an academic job. Here I will discuss why some trainees choose to go for an advanced fellowship and the challenges associated with such fellowships.
Advanced fellowships are usually 1 to 2 years of specialized training in a specific branch of oncology. Examples include bone marrow transplant, transfusion medicine, leukemia, lymphoma, gastrointestinal cancers, breast cancer, palliative care, and others. Those fellowships are usually offered at large cancer institutes/university programs and are universally not accredited by the Accreditation Council for Graduate Medical Education (ACGME). Some advanced fellowship programs will not require hematology-oncology training and are open to trainees who only completed their training in internal medicine and/or pediatrics. Many other international oncologists get benefits from advanced fellowship training. In many cases, advanced fellowships are needed by the institutions more than they are needed by the trainees.
Why do some trainees choose to do an advanced fellowship?
The most common reason is to get better in a specific branch of oncology. This includes more patient exposure and more scholarly activities. Moreover, it helps in building mentor relationships in the area of interest. Many trainees will start by doing an advanced fellowship that will extend into a junior faculty job in the same institution, or even another institution. Some trainees may need to learn more about a specific disease prior to deciding on an area of interest. Some international medical graduates who complete their training in the U.S. may choose to do an advanced fellowship before going back to their home country to practice.
What are the pros and cons of an advanced fellowship?
There is no doubt that an advanced fellowship will provide more time for a trainee to grow and improve in their field of interest. This is likely due to the specific interest of some trainees in a specific field, but more likely is due to the fact that some training programs may not offer the desired training in this specific field. Most academic programs have the ability to offer a specific training, though they are forced to cover multiple required rotations to ensure balanced training in all the fields of hematology and oncology. A dynamic training that fits the trainee needs will be more appropriate and can result in better training outcomes.1 It will also prepare the trainee for a junior faculty role without the need of an advanced fellowship.
It is extremely significant to keep in mind that most trainees face financial hardships when extending the training time. This includes rising debts from medical school education, delaying retirement savings, and the growing need to support their families. For example, primary care physicians in their first 3 to 5 years following residency will have expenses that exceed their earnings.2 This potentially results in avoiding primary care as a future job for many medical graduates. The same will be true in academic oncology jobs in the future. A calculation of the economic ramifications of pursuing a career in academic hematology estimated in at least $11,000 yearly lower net income after projected expenses when comparing 3 versus 5 years of training.3 The deficit will be even higher when comparing academic with private jobs.
Should we stop offering advanced fellowships?
I believe that we should change the current advanced fellowships to junior faculty jobs. This will be helpful in many aspects. It will provide similar chances of career development and growth, while allowing for more decision-making opportunities and improved compensation. This will be possible by adjusting the hematology and oncology training to be more focused toward the trainee’s goals, especially for trainees interested in academic jobs.1
Here I present a common example of a situation that many trainees face: A trainee who started hematology and oncology was not sure what branch of oncology they will be practicing or what they are most interested in doing. They will spend the first 1 to 2 years exploring the field and decide on a branch of interest. They will decide to pursue a breast oncology academic job. They will have a modified training in the last 1 to 2 years that will allow for more patient exposure and allocated research time. This will help the majority of trainees obtain a specific academic oncology job in the future without the need to complete an advanced fellowship. It is also increasingly common that some trainees may know their field of interest before joining the fellowship program, which will help them adapt to any change in their interest while in training.
Advanced fellowships in oncology: Do I need one?
We need to make the answer no. The answer in our current system will likely be it depends. Trainees who want to pursue private practice/non-academic jobs will not need one most of the time. Some private practice jobs may have areas of practice that require more training in a specific area, which can be achieved with dynamic training programs. In the case of academic interest, an advanced fellowship should not be required before joining an academic job. It is known that a junior faculty job is a continuum of training, especially in first 1 to 3 years. It can be thought of as an advanced fellowship with better career development and compensation. If we change our thinking about advanced fellowships, we can allow more trainees to join the academic workforce while maintaining their roles as human beings with personal and family commitments.
There is no doubt that we should work to improve the structure of oncology training to better fit the trainees’ needs, and not just the training institutions’. There are multiple reasons why a trainee may choose to do an advanced fellowship, but the majority will choose to do a junior faculty job if both decisions are on the table. The junior faculty job includes similar mentoring and educational growth, but it will also be associated with better career development and compensation, as well as improvement in the ability to make treatment decisions. Advanced fellowships may be an option for international oncologists interested in doing a brief training in an area of interest for a short period of time. Otherwise, for U.S. graduates who want to pursue a job in the United States, an advanced fellowship should be changed to a junior faculty job.
Dr. Al Hadidi is a third-year fellow in the Section of Hematology and Oncology at Baylor College of Medicine, and a member of the ASCO Trainee Council. His research interests include areas related to hematologic oncology, with a focus on drug development, health equity, and medical education. Follow Dr. Al Hadidi on Twitter @HadidiSamer. Disclosure.
- Al Hadidi S. Hematology and Oncology: Is It Time for Divorce? ASCO Connection. Dec 3, 2020.
- Palmeri M, Pipas C, Wadsworth E, et al. Economic impact of a primary care career: a harsh reality for medical students and the nation. Acad Med. 2010;85:1692-7.
- Woyach J, Palmeri M, Kuo K. The Perpetual Fellow — Extending Fellowship Training in Hematology: The Trainee Perspective. The Hematologist. Mar 1, 2011.